FAMILY AND INFANT

Traditionally, infancy is designated as the period of time from 1 month to 1 year of age. In these important
months, an infant undergoes such rapid development that parents sometimes believe their baby looks different
and demonstrates new abilities every day. During this time, an infant typically triples birth weight and increases
length by 50%. Babies’ senses sharpen, and with the process of attachment to a primary caregiver, they form a
first social relationship. Because of the growth and learning potential that occurs, this first year is a crucial one.

PLAY

Play during infancy represents the various social modalities observed during cognitive development.
Infants’ activity is primarily narcissistic and revolves around their own body. As discussed under Development of
Body Image (p. 876), body parts are primarily objects of play and pleasure.

During the first year, play becomes more sophisticated and interdependent. From birth to 3 months,
infants’ responses to the environment are global and largely undifferentiated. Play is dependent; pleasure is
demonstrated by a quieting attitude (1 month), a smile (2 months), or a squeal (3 months). From 3 to 6 months,
infants show more discriminate interest in stimuli and begin to play alone with a rattle or a soft stuffed toy or with
someone else. There is much more interaction during play. By 4 months of age, they laugh aloud, show a
preference for certain toys, and become excited when food or a favorite object is brought to them. They recognize
an image in a mirror, smile at it, and vocalize to it.

By 6 months to 1 year, play involves sensorimotor skills. Actual games such as peekaboo and pat-a-cake
are played. Verbal repetition and imitation of simple gestures occur in response to demonstration. Play is much
more selective, not only in terms of specific toys but also in terms of “playmates.” Although play is solitary or
one-sided, infants choose with whom they will interact. At 6 to 8 months, they usually refuse to play with strangers.
Parents are definite favorites, and infants know how to attract their attention. At 6 months, they extend the arms
to be picked up; at 7 months, cough or squeal to make their presence known; at 10 months, pull the parent’s
clothing; and at 12 months, call them by name. This represents a tremendous advance from the newborn, who
signaled biologic needs by crying to express displeasure.

Stimulation is as important for psychosocial growth as food is for physical growth. Knowledge of
developmental milestones allows nurses to guide parents regarding proper play for infants. It is not sufficient to
place a mobile over a crib and toys in a play yard for a child’s optimal social, emotional, and intellectual
development. Likewise, the television or recorded videos, for the most part, do not provide infants with
appropriate sensory stimulation, do not increase language skills, and should therefore be restricted in children
younger than 2 years (AAP Council on Communications and Media, 2011). Play must provide interpersonal
contact and recreational and educational stimulation. Infants need to be played with, not merely allowed to play.
Although the type of play infants engage in is called solitary, this is a figurative, not literal,
term to denote one-sided play. The type of toys given to the child is much less important than the quality of
personal interaction that occurs.
NUTRITION

Birth to 6 Months
• Breast Milk is the most desirable complete diet for the infant during the first 6 months.
• The healthy term infant receiving breast milk from a well-nourished mother usually requires no specific
vitamin and mineral supplements, with a few exceptions.
➢ Daily supplements of vitamin D and vitamin B12 may be indicated if the mother’s intake of these
vitamins is inadequate.
➢ The AAP (2008) recommends that all infants (including those exclusively breastfed) receive a
daily supplement of 400 international units (IU) of vitamin D beginning in the first few days of life
to prevent rickets and vitamin D deficiency.
• Infants, whether breastfed or bottle-fed, do not require additional fluids, especially water or juice, during
the first 4 months of life.
➢ Excessive intake of water in infants may result in water intoxication and hyponatremia.
• Employed mothers can continue breastfeeding with guidance and encouragement.
➢ Mothers are encouraged to set realistic goals for employment and breastfeeding, with accurate
information regarding the costs, risks, and benefits of available feeding options.
• Expressed breast milk may be stored in the refrigerator (4° C [39° F]) without danger of bacterial
contamination for up to 5 days
➢ Breast milk may be expressed by hand or pump (manual or electric) and stored in an appropriate
air-tight glass or plastic container.

• An acceptable alternative to breastfeeding is commercial iron-fortified formula.

➢ Like human milk, it supplies all nutrients needed by the infant for the first 6 months.
• Unmodified whole cow’s milk, low-fat cow’s milk, skim milk, other animal milks, and imitation milk drinks
are not acceptable as a major source of nutrition for infants.
➢ Because of their limited digestibility, increased risk for contamination, and lack of components
needed for appropriate growth.
• The amount of formula per feeding and the number of feedings per day vary among infants.
• Infants being fed on demand usually determine their own feeding schedule, but some infants may need
a more planned schedule based on average feeding patterns to ensure sufficient nutrients.
➢ In general, the number of feedings decreases from six at 1 month of age to four or five at 6 months.
➢ Regardless of the number of feedings, the total amount of formula ingested will usually level off
at about 32 ounces (946 mL) per day.

• The addition of solid foods before 4 to 6 months of age is not recommended.

➢ During the early months, solid foods are not compatible with the ability of the gastrointestinal tract
and infant’s nutritional needs.
➢ Feeding solids to young infants exposes them to food antigens that may produce food protein
allergy.
o There is ample evidence that early introduction of foods other than maternal milk in the
first 6 months of life predisposes children to an increased risk for food allergy development;
• Developmentally, infants are not ready for solid food.
➢ Infants instinctively suck when given food. Because of their limited motor abilities, infants are
unable to deliberately push food away or avoid feeding.
• Therefore, early introduction of solids is a type of forced feeding that may lead to excessive weight gain
and increased predisposition to allergies and iron deficiency anemia.

7 to 12 Months
• During the second half of the first year, human milk or formula should optimally continue to be the primary
source of nutrition.
• If breastfeeding is discontinued, a commercial iron-fortified formula should be substituted.
• Take Note: Follow-up or transition formulas marketed for older infants offer no special advantages over
other infant formulas and provide excessive protein.

• The major change in feeding habits is the addition of solid foods to the infant’s diet.
• Physiologically and developmentally, the infant 4 to 6 months of age is in a transition period.
• By this time, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is
less sensitive to potentially allergenic foods.
• The extrusion reflex has disappeared, and swallowing is more coordinated to allow the infant to accept
solids easily.
• Head control is well developed, which permits infants to sit with support and purposely turn the head
away to communicate lack of interest in food.
• Their increasing sense of independence is evident in their desire to hold the bottle and try to “help” during
feeding.

Recommended Food during this period:

 • Infant cereal (Iron Fortified)
• Fruit juice
➢ Large quantities of certain juices (e.g., apple, pear, prune, sweet cherry, peach, grape) should be
avoided because they may cause abdominal pain, diarrhea, or bloating in some children.
• Strained Fruits
• Vegetables
• Meat

Remember:
• The introduction of solid foods into the infant’s diet at this age is primarily for taste and chewing
experience, not for growth.
• Parents are cautioned to avoid reliance on food supplements marketed as iron- or vitamin-fortified as
primary sources of minerals.
➢ Instead, encourage parents to offer the child a variety of fruits, vegetables, and whole grains,
including those known to naturally be rich in iron.

Introduction of Solid Food

• When the spoon is first introduced, infants often push it away and appear dissatisfied.
• Patience and skill are required to overcome this initial response.
• A small-bowled, straight, long-handled spoon, similar to a demitasse spoon, allows a small portion of
food to be placed toward the back of the tongue.
• How?
➢ Introduce solids when infant is hungry.
➢ Begin spoon-feeding by pushing food to back of tongue because of infant’s natural tendency to
thrust the tongue forward.
➢ Use a small spoon with a straight handle; begin with 1 or 2 teaspoons of food; gradually increase
to a couple of tablespoons per feeding.
➢ Introduce one food at a time, usually at intervals of 4 to 7 days, to allow for identification of food
allergies.
➢ As the amount of solid food increases, decrease the quantity of milk to prevent overfeeding.
➢ Do not introduce foods by mixing them with formula in the bottle.

SLEEP
• Sleep patterns vary among infants, with active infants typically sleeping less than placid children.
• Generally, by 3 to 4 months of age, most infants have developed a nocturnal pattern of sleep that lasts 9
to 11 hours.
• The total daily sleep is approximately 15 hours.
• Breastfed infants usually sleep for shorter periods, with more frequent waking, especially during the night,
compared with bottle-fed infants.

ACTIVITY
• Most infants are naturally active and need no encouragement to be mobile.
• Problems can arise when devices such as play yards, strollers, commercial swings, and mobile walkers
are used excessively.
➢ These items restrict movement and prevent infants from exploring and developing gross motor
skills.
• Contrary to popular belief, mobile walkers do not enhance coordination and are dangerous if tipped over
or placed near stairs.

DENTAL HEALTH
• Good infant dental hygiene begins with appropriate maternal dental health before and during the
pregnancy and counseling during early infancy regarding dietary intake for the promotion of optimal oral
hygiene.
• Parents are counseled early regarding feeding practices that increase the risk for poor dental health.
• Some of these, as previously mentioned, include propping the milk bottle, giving the milk bottle in the bed,
or giving fruit juices in a bottle, especially before 6 months of age.
➢ These contribute to enamel erosion and early childhood caries (previously called baby bottle tooth
decay).
➢ Parents should also be made aware that dental caries is contagious and can be prevented with
optimal oral hygiene starting in infancy.

• Once the primary teeth erupt, cleaning should begin.

• The teeth and gums are initially cleaned by wiping with a damp cloth; toothbrushing is too harsh for the
tender gingiva.
• It is recommended that the infant have a brief oral health examination by 6 months of age from a qualified
pediatric health care practitioner.
 • It is generally recommended that a small, soft-bristled toothbrush be used as more teeth erupt and the
infant adjusts to the routine of cleaning.
• Water is preferred to toothpaste, which the infant will swallow.
• Fluoride, an essential mineral for building caries-resistant teeth, is needed beginning at 6 months of age
if the infant does not receive water with adequate fluoride content.

IMMUNIZATIONS
• One of the most dramatic advances in pediatrics has been the decline of infectious diseases during the
twentieth century because of the widespread use of immunization for preventable diseases.
• However, childhood vaccines have been widely criticized in recent years, and fear related to vaccine
components has prompted some families to avoid childhood vaccines.
➢ The Internet provides a variety of information suggesting parents avoid childhood vaccines; a
number of “vaccine myths” exist, which are based on erroneous information.
• Nurses are in the right position to provide parents with accurate information regarding childhood illnesses
and available vaccines; the parent must then make an informed decision regarding the child’s
vaccinations.
• The recommended primary schedule begins during infancy and, with the exception of boosters, is
completed during early childhood.

Summary of Vaccines, Schedules, and Protection Provided

VACCINE SCHEDULE PROTECTION FROM:
BCG At birth Tuberculosis
HepB At birth Hepatitis B
OPV 6, 10, 14 Weeks Poliovirus
IPV 14 Weeks Poliovirus
Diphtheria, Pertussis, Tetanus,
PENTA 6, 10, 14 Weeks
Influenza B, and Hepatitis B
PCV 6, 10, 14 Weeks Pneumonia and Meningitis
RV 6 to 10 Weeks Rotaviruses
MMR 9 months and 12 months Measles, Mumps, and Rubella

Expanded Program on Immunization Schedule (From the Department of Health)

MENTAL FUNCTION AND PERSONALITY DEVELOPMENT DURING THIS PERIOD
• Personality and cognitive skills develop in much the same manner as biologic growth—
new accomplishments build on previously mastered skills.
• Many aspects depend on physical growth and that prevents individuals from expressing
undesirable instincts that might threaten the social order

Summary Of Personality, Cognitive, And Moral Development Theories (0 to 12 Months)

Psychosexual
Oral
(Freud)
Psychosocial
Trust vs. Misturst
(Erikson)
Cognitive
Sensorimotor (Birth to 2 Years)
(Piaget)
Moral Judgement
n/a
(Kohlberg)
Spiritual
Undifferentiated
(Fowler)

Psychosexual Stages – Freud

• Freud considered the sexual instincts to be significant in the development of the
personality.
• However, he used the term psychosexual to describe any sensual pleasure.
• For an infant aging from birth to 1 year, Freud categorized it as the Oral Stage.

Oral Stage
• During infancy, the major source of pleasure seeking is centered on oral activities such as
sucking, biting, chewing, and vocalizing.
• Infants may prefer one of these over the others, and the preferred method of oral
gratification can provide some indication of the personality they develop.

Psychosocial Development – Erikson

• This is considered to be the most widely accepted theory of personality development.
• Erikson also uses the biologic concepts of critical periods and epigenesis, describing key
conflicts or core problems that the individual strives to master during critical periods in
personality development.
• Each psychosocial stage has two components (i.e., the favorable and the unfavorable
aspects of the core conflict), and progress to the next stage depends on resolution of this
conflict.
• During infancy stage, it is trust vs mistrust

Trust vs. Mistrust

• The first and most important attribute to develop for a healthy personality is basic trust.
➢ Establishing basic trust dominates the first year of life and describes all of the
child’s satisfying experiences at this age.
• Consistent, loving care by a mothering person is essential for development of trust.
• Mistrust develops when trust-promoting experiences are deficient or lacking or basic
needs are inconsistently or inadequately met.
➢ Although shreds of mistrust are sprinkled throughout the personality, from a basic
trust in parents stems trust in the world, other people, and oneself.
• The result is faith and optimism.
Cognitive Development – Piaget
• Cognitive development consists of age-related changes that occur in mental activities.
• According to Piaget intelligence enables individuals to make adaptations to the
environment that increase the probability of survival; and through their behavior individuals
establish and maintain equilibrium with the environment.
• In the stages, infants belong to the sensorimotor stage.

Sensorimotor (Birth to 2 Years)

• Children progress from reflex activity through simple repetitive behaviors to imitative
behavior.
• They develop a sense of cause and effect as they direct behavior toward objects.
• Problem solving is primarily by trial and error.
• They display a high level of curiosity, experimentation, and enjoyment of novelty and begin
to develop a sense of self as they are able to differentiate themselves from their
environment.
• They become aware that objects have permanence (i.e., that an object exists even though
it is no longet visible).
• Toward the end of the sensorimotor period, children begin to use language and
representational thought.

Spiritual Development – Fowler

• Spiritual beliefs are closely related to the moral and ethical portion of the child’s self-
concept and as such must be considered as part of his or her basic needs assessment.
• In the 7 stages of the development of faith according to Fowler, infants belong to Stage 0:
Undifferentiated

Stage 0: Undifferentiated
• This stage of development encompasses the period of infancy during which children have
no concept of right or wrong, no beliefs, and no convictions to guide their behavior.
• However, the beginnings of a faith are established with the development of basic trust
through their relationships with the primary caregiver.

FEAR

Stranger Fear
• As infants demonstrate attachment to one person, they correspondingly exhibit less
friendliness to others.
• Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent
and are related to infants’ ability to discriminate between familiar and unfamiliar people.
• Behaviors such as clinging to the parent, crying, and turning away from the stranger are
common.

9 Months of Age – Begins to show fears of going to bed and being left alone

12 Months of Age – Infant is fearful in strange situation; clings to their parent.